Exhaustion disorder: scoping review of research on a recently introduced stress-related diagnosis

Background Symptoms related to chronic stress are prevalent and entail high societal costs, yet there is a lack of international consensus regarding diagnostics and treatment. A new stress-related diagnosis, exhaustion disorder, was introduced into the Swedish version of ICD-10 in 2005. Since then, use of the diagnosis has increased rapidly. Aims To create the first comprehensive synthesis of research on exhaustion disorder to report on the current state of knowledge. Preregistration: Open Science Framework (osf.io), doi 10.17605/OSF.IO/VFDKW. Method A PRISMA-guided scoping review of all empirical studies of exhaustion disorder was conducted. Searches were run in the MEDLINE, PsycInfo and Web of Science databases. Data were systematically charted and thematically categorised based on primary area of investigation. Results Eighty-nine included studies were sorted into six themes relating to lived experience of exhaustion disorder (n = 9), symptom presentation and course (n = 13), cognitive functioning (n = 10), biological measures (n = 24), symptom measurement scales (n = 4) and treatment (n = 29). Several studies indicated that individuals with exhaustion disorder experience a range of psychiatric and somatic symptoms beyond fatigue, but robust findings within most thematic categories were scarce. The limited number of studies, lack of replication of findings and methodological limitations (e.g. small samples and scarcity of specified primary outcomes) preclude firm conclusions about the diagnostic construct. Conclusions More research is needed to build a solid knowledge base for exhaustion disorder. International collaboration regarding the conceptualisation of chronic stress and fatigue is warranted to accelerate the growth of evidence.


Content
Pages Table S1. Full search strategy 2  (sweden or lund or linkoping or stockholm or gothenburg or umea or uppsala or karlstad or orebro or ostersund or vaxjo).in.
(sweden or lund or linkoping or stockholm or gothenburg or umea or uppsala or karlstad or orebro or ostersund or vaxjo).in.

First author
Year Design Aim/question Lived experience of ED, n = 2 Gustafsson 1 2008 Qualitative To illuminate the meanings of becoming and being burned out as narrated by healthcare personnel on sick leave because of symptoms of burnout. Håkansson 2 2010 Qualitative To re-analyze the data for its congruence with the Matuska and Christiansen life balance model using a matrix system, and to test the validity of the model.

Symptoms, course and context, n = 10
Asplund 3 2021 Cross-sectional To assess the prevalence of self-rated exhaustion disorder (s-ED), describe plausible between-group differences in self-reported health-related factors among employees with or without s-ED, and identify health-related factors associated with s-ED.

Broddardottír 4 2021 Cross-sectional
To identify ED patients whose fatigue meets criteria for "persistent physical symptoms" (PPS) and explore whether they differ from other ED patients in terms of psychological distress, non-fatigue PPSs and functional impairment, inspecting whether this alternative formulation of the fatigue problem might be more appropriate. Gustafsson 5 2009 Cross-sectional, case control To describe patterns of personality traits among two groups of health-care personnel from the same workplaces, one group on sick leave due to medically assessed burnout, and one group with no indication of burnout, respectively Gustafsson 6 2010 Cross-sectional, case control To elucidate perceptions of conscience, stress of conscience, moral sensitivity, social support and resilience among two groups of health care personnel from the same workplaces, one group on sick leave owing to medically assessed burnout and one group who showed no indications of burnout.

Håkansson 7 2018 Longitudinal, cohort
To investigate whether perceived occupational imbalance predicts stress-related disorders and possible gender differences. To explore the mediating role of perceived stress in the association between occupational imbalance and stress-related disorders.

Höglund 8 2020 Cross-sectional
To determine symptom severity of anxiety, depression, insomnia, burnout and somatization in combinations of different age groups and sex. To determine prevalence of caseness of these types of mental ill-health in both absolute and relative terms in the combinations of age groups and sex.

Norlund 9 2011 Cohort, prospective
To investigate the impact of psychosocial working conditions and coping strategies at work on change in sick leave level for patients on long-term sick leave due to burnout.
Stenlund 10 2007 Case control To describe gender differences in patients with burnout and compare these patients with a general population with respect to physical, psychosocial and work variables.

Söderström 11 2012 Prospective
To identify risk factors for subsequent clinical burnout. Wiegner 12 2015 Observational, Cohort To examine to what extent a working age population seeking primary health care perceives stress, as well as symptoms of burnout/exhaustion, depression and anxiety.
Cognitive functioning, n = 1 Sandström 13 2005 Cross-sectional, case control To conduct a thorough examination of the cognitive performance of patients with a diagnosis of chronic burnout Biological measures, n = 10 Blix 14 2013 Cross-sectional, case control To examine whether chronic work-related stress is associated with changes in brain structure. To compare functional magnetic resonance imaging (fMRI) patterns and diurnal cortisol across three groups: (i) controls, (ii) acute un-medicated patients with unipolar major depression, and (iii) patients on long-term sick leave due to work stress. Savic 23 2015 Repeated measures, case control To compare salivary cortisol, cortical thickness, cortical surface area and subcortical volumes between individuals with occupational stress compared to controls. Glise 24 2010 Longitudinal, cohort

Symptom measurement scales, n = 4
To assess the construct and predictive validity of a new instrument for self-rating of stress-related Exhaustion Disorder (s-ED).
Persson 25 2016 Cross-sectional To benchmark the Lund University Checklist for Incipient Exhaustion (LUCIE) against the s-ED and the Karolinska Exhaustion Disorder Scale, but also against other ED-related concepts such as burnout.
Persson 26 2017 Cross-sectional To examine the relationships of two screening instruments recently developed for assessment of ED with some other well-known inventories intended to assess ED-related concepts and self-reports of job demands, job control, job support, private life stressors, and personality factors. Interventions, n = 12 Cerwén 28 2016 Qualitative To increase understanding of the role of soundscapes in Nature Based Rehabilitation (NBR),

Fjellman-Wiklund 29 2010 Qualitative
To explore patients' experiences in a burnout rehabilitation programme with two different rehabilitation groups.

Grahn 30 2017 Longitudinal, cohort
To examine return to work a year after the start of participation in nature-based rehabilitation programs with different lengths (8,12, and 24 weeks).
Grossi 31 2009 Longitudinal, case control To determine whether complementary therapy based on a group treatment program could improve the patients' health, physiological markers and work capacity better than the standard individual treatment program offered by the municipal company healthcare.
Heiden 32 2007 RCT To evaluate the effects of a cognitive behavioural training programme and a physical activity programme, compared with usual care, for patients with stress-related illnesses.
Nygren 33 2019 Longitudinal, case control To examine whether a combination of a multimodal rehabilitation, group-talks with collegues, and active monitoring (intervention carried out on an all-inclusive hotel in Gran Canaria) leads to improved return-to-work rates in sick-listed teachers with exhaustion disorder compared with treatment as usual.
Pálsdóttir 34 2014 Mixed method To describe and assess changes in participants' experiences of everyday occupations after nature-based vocational rehabilitation and to assess changes regarding symptoms of severe stress and the rate of return to work and possible association with experiencing the occupational value of everyday occupations.

Pálsdóttir 35 2014 Qualitative, longitudinal
To explore and illustrate how participants with stress-related mental disorders participating in nature-based rehabilitation experience and describe their rehabilitation process in relation to the role of the natural environments.
Person-Asplund 36 2018 RCT To evaluate the efficacy of a guided internet-based stress management intervention among distressed managers compared with an attention control group with full access to treatment-as-usual.

Sahlin 37 2015 Longitudinal, cohort
To explore the effects of nature-based rehabilitation in patients with exhaustion disorder or stress-related mental disorders.
Stenlund 38 2009 RCT To evaluate effects on psychological variables and sick leave rates by two different group rehabilitation programs for patients on long-term sick leave because of burnout.

Stenlund 39 2012 RCT, secondary publication
To evaluate the long-term effects of two different rehabilitation programs for patients on long-term sick leave for burnout.
RCT, randomized controlled trial Table S3a. In-depth data-charting of primary publications of quantitative studies included in the review that investigated interventions for exhaustion disorder.   Confirm potential biomarkers of prolonged psychosocial stress in female ED participants suggested in a former study: monocyte chemotactic protein-1 (MCP-1), epidermal growth factor (EGF) and vascular endothelial growth factor (VEGF). To compare plasma levels of different isoforms of VEGF, including VEGF121, VEGF165, and VEGF121+VEGF165 (VEGFtotal) in individuals with ED, patients with major depressive disorder (MDD), and healthy controls. Symptom measurement scales, n = 4 Axelsson 113 2017 † Longitudinal 160 78 To study the psychometric properties of the 12-item self-report WHODAS 2.0 when administered online to individuals with anxiety and stress disorders. Longitudinal 179  70 To evaluate the Psychological general well-being index (PGWBI) with Rasch-and factor analysis.

Interventions, n = 29
Adevi 117 2012 Qualitative 5 80 Explore caregiver perspective on factors considered most essential to the recovery process of patients with ED. Adevi 118 2013 Qualitative 5 80 Explore the impact of garden therapy on stress-rehabilitation with a special focus on nature.    To gain insight into the existential experience of clinical burn-out as well as to highlight the significance of an existential perspective in rehabilitation.

Finnes, 2018 Stockholm, Sweden
Return to work -methods for promoting health and productivity in employees on sickness absence To evaluate the effect of psychological interventions on sickness absence and return to work.

Glise, 2014 Gothenburg, Sweden
Exhaustion disorder -identification, characterization, and course of illness To study exhaustion disorder (ED) with respect to identification, characterization, and course of illness. Additionally, to study properties of an instrument of self-rated ED (s-ED).

Grensman, 2020 Stockholm, Sweden
Traditional yoga and clinical burnout -quality of life and biomarkers before and after treatment To understand the situation of patients with clinical burnout (CB) on sick leave, to investigate the effect of traditional yoga (TY) on CB, and whether there are subjective and objective measures that can be used for screening to diagnose CB, to follow the course, and evaluate treatment effects. Gustafsson, 2009 Umeå, Sweden (In Swedish † ) To become or not to become burned out -a complex phenomenon among healthcare professionals in the same workplaces* To describe the meaning of becoming burnt out and describe personality traits and views on conscience, stress, moral and social support among ED and non-ED participants.
Lindsäter, 2020 Stockholm, Sweden Cognitive behavioral therapy for stress-related disorders To build and expand on the limited knowledge base regarding CBT as a treatment for stress-related disorders by further investigating clinical efficacy, cost-effectiveness, and mediators of change in treatment.

Malmberg Gavelin, 2019
Umeå, Sweden Rehabilitation for improved cognition in stress-related exhaustion -cognitive neural and clinical perspectives To evaluate the efficacy of additional cognitive and aerobic training for patients with ED who participated in a multimodal stress rehabilitation program and to explore the neural correlates of ED.
Norlund, 2011 Umeå, Sweden Psychosocial work factors and burnout -a study of a working general population and patients at a stress rehabilitation clinic To assess the level of burnout in a working general population and investigate the importance of psychosocial work factors and sex on burnout and to study reduction of sick leave and experiences of returning to work in burnout patients, with special attention towards psychosocial work factors. Persson Asplund, 2021 Linköping, Sweden Learning how to recover from stress-related disorders via internet-based interventions To bring further evidence to the field on the experiences and efficacy of internet-based and work-focused interventions for employees with stress-related disorders. Sahlin, 2014 Alnarp, Sweden To stress the importance of nature -nature-based therapy for the rehabilitation and prevention of stress-related disorders To explore whether Nature-Based Therapy (NBT) for prevention and rehabilitation positively affected participants' health and well-being; that is, their physical and mental health and well-being, as well as their ability to function in everyday life.

Salomonsson, 2018 Stockholm, Sweden
CBT in primary care -effects on symptoms and sick leave, implementation of stepped care and predictors of outcome To implement and evaluate evidence-based CBT, to evaluate CBT for adjustment and exhaustion disorders, and to evaluate an intervention to reduce sick leave (RTW-I) among patients with common mental disorders in primary care.

Santoft, 2019 Stockholm, Sweden
What makes cognitive behavior therapy work? An investigation of psychological and inflammatory processes To investigate processes and correlates of therapeutic change in CBT for common mental disorders. Sonntag-Öström, 2014

Umeå, Sweden
Forest for rest -recovery from exhaustion disorder To study whether visits to different kinds of forest environments have positive health effects on patients suffering from ED and can be utilized for rehabilitation.  Umeå, Sweden Rehabilitation for patients with burnout To describe patients on long-term sick leave because of burnout and to evaluate rehabilitation programs for this patient group.

Söderström, 2012 Stockholm, Sweden
Burnout -a matter of impaired recovery? To investigate physiological and subjective markers of recovery from stress to identify and discuss possible risk factors precipitating burnout, as well as factors related to recovery from burnout and return to work. Sleep and unwinding during leisure time were in particular focus.

Wahlberg, 2012 Stockholm, Sweden
Stress reactivity, cognitive functioning and hippocampal morphology in exhaustion disorder, and development of a self-rating scale for exhaustion disorder, KEDS To obtain insights into the biological process associated with work stress related depression and exhaustion disorder in women, and to construct and evaluate a self-rating scale for assessment of symptoms of exhaustion disorder. † Translation to English by research team